Patient-Centered Medical Home

1. Patient-Centered Medical Home WVACHE Spring Educational Offering April 20, 2012

2. Moderator David K. McClure, FACHE V.P. Operations Camden Clark Medical Center

3. Goals and Objectives • Heightened your awareness of: • Transformation to Accountable Care • Overarching aspects of a patient-centered medical home (PCMH) • Components of a PCMH and the use of clinical integration, IT and risk sharing • Developing evidence-based medical practices

4. Healthcare Policy: The Future of Health Reform

5. Healthcare Policy: At Risk and Accountable Health care reimbursement will come from “at risk” payment strategies or through an Accountable Care Organization. • Move forward on an IT infrastructure that can reliably reflect clinical and administrative functions. • Look for ways to reduce waste and improve processes. • Develop partnerships in the medical marketplace.

6. Payment: Paying for More An increasing number of caregiver activities that can potentially reduce costs and manage chronic disease (e.g., telephone or e-visits) will be reimbursed. • Make sure that information and management systems can reliably capture these unconventional activities. • Promote these encounters by educating patients and caregivers on the convenience and value of these activities. • Help physicians successfully integrate these activities into their practices.

7. Integration: Codependence The Affordable Care Act’s promotion of Accountable Care Organizations (ACOs) and bundled payment mechanisms will mean that all healthcare providers will be codependent. • Reduce costs, including admissions and diagnostics that don’t contribute to positive outcomes. • Develop relationships that integrate clinical functions and align incentives. • Evaluate your organization’s readiness to become an ACO and or partner with an ACO.

8. Integration The anticipation of healthcare reform has already prompted many healthcare providers to seek close alliances with hospitals and collaborate with insurers. This trend will only intensify. • Be sensitive to the patient’s needs • Create programs that incentivize quality and productivity. • Develop or expand leadership opportunities.

9. Integration: Broader Missions With more physician partners, hospitals and insurers will expand their mission statements to include care in pre- and post-hospital settings. • Engage your organizations board in setting a broader agenda. • Investigate risk sharing regarding care rendered outside the acute-care hospital. • Consider affiliations with other systems in order to diversify services and gain access to capital.

10. Practice Management Skills Hospitals, insurers and Physicians will need the knowledge and skills to manage and coordinate healthcare practices. • Work with physicians to develop an infrastructure that tracks and drives clinical performance. • Expand physician leadership and training opportunities.

11. Primary Care: Impact of Reform The development of Primary Care Medical Homes and Accountable Care Organizations will result in tighter clinical integration between hospitals, primary care and specialty care. • Monitor federal regulations and the results of demonstration projects closely. • Make sure information systems can reliably integrate the clinical and management functions. • Work with physician leadership to ensure the medical staff is up to date on guidelines and other care standards.

12. Primary Care: Unprecedented Demand The already growing demand for primary care services will increase dramatically in 2014, the year that the Affordable Care Act expands coverage. • Work with educational institutions and provide scholarships or tuition assistance to primary care students in exchange for future service. • Develop partnerships with other community providers (e.g., FQHCs) that employ primary care physicians.

13. Primary Care:Reliance on Extenders Within the next few years, the bulk of primary care services will be provided by clinical extenders. Insurers will reimburse these services. • Re-examine the traditional ratios and roles of PAs and NPs to physicians. • Help physicians learn to collaborate with physician extenders to ensure continuity of care.

14. Primary Care: New Models Demand for traditional primary care services will continue to outpace supply in the foreseeable future, necessitating the development of new models and approaches. • Work with nursing leadership to ensure nurses are practicing to the full extent of their education and training. • Monitor trends in education and public policy. • Look for novel approaches and ways that IT can extend the reach of primary care providers.

15. PCMH: Health Care Organization Perspective Martha Carter, CNM, MBA CEO FamilyCareHealthCenter

16. Triple Aim • Improve the health of the population; • Enhance the patient experience of care (including quality, access, and reliability); and • Reduce, or at least control, the per capita cost of care Institute for Healthcare Improvement. (2011). The IHI Triple Aim. Retrieved from http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx

17. Overarching Changes • Locus of control shifting more to patient • Providers and provider organizations increasingly accountable for patient health outcomes and cost of care

18. PCMH Standards • Enhance access and continuity • Identify and manage patient populations • Plan and manage care • Provide self-care and community support • Track and coordinate care • Measure and improve performance NCQA. (2011). Patient-Centered Medical Home. NCQA. Retrieved from http://www.ncqa.org/tabid/631/default.aspx

19. Medicare ACO Shared Savings ProgramQuality Measures • Patient/caregiver experience (7 measures) • Care coordination/patient safety (6 measures) • Preventive health (8 measures) • At-risk populations (12 measures) • ACOs are eligible for shared savings only if also meeting quality goals (phased in over 3 years) Centers for Medicare & Medicaid Services. (2012, April 6). Shared Savings Program. Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/index.html?redirect=/sharedsavingsprogram/01_Overview.asp#TopOfPage

20. Change = Challenge • How to design primary care delivery to be more efficient and reach more people • How to use IT to manage care of individuals and of populations • How to develop relationships with patients to influence health decisions • How to develop inter-agency relationships to improve care and reduce cost • How to realign goals with reimbursement • How to finance the necessary changes & maintain financial stability in transition

21. The health care system is in transition and we have a foot in both worlds Pay for Volume ? Pay for Quality

22. Change = Opportunity • Develop body of evidence to show what works • Reduce perverse incentives that support high-cost care • Enhance roles of health care team members • Explore new models of coordinated care • Design models of accountable care

23. PCMH:An Insurers Perspective Linda WeilandVP, Provider Network Innovations & Partnerships Highmark West Virginia

24. Agenda Current healthcare landscape The power of the accountable care delivery models: Patient Centered Medical Home - and Partnering (Healthcare Providers – Patients- Payers) to Transform Care Delivery

25. Today’s Underlying Problem The USA spends significantly more than any other industrialized nation on health care. “ The USA spends significantly more than any other industrialized nation on health care. 2

26. The U.S. has the highest per capita public and % GDP spend- nearly 25 times the average of other industrialized nations, and yet the poorest outcomes in mortality and cancer survival rates. 3

27. 4

28. The current healthcare delivery system and mode of operation is unsustainable. Spending on healthcare in the United States is growing at a rate of 6–8%. Uncontrolled costs=> Care Fragmentation=> Waste=> Duplication=> Preventable Errors – Poor Quality and Care Outcomes Impetus of the Reform Agenda 5

29. Illness- Wellness Assessment 2010

30. PCPs are the foundation of the healthcare delivery system Patient Centered - PCP Directed

31. Triple Aim Goals : Population and Individual Health, Reduced per capita costs (Value), Improved care experience and access to care for patients and Improved provider satisfaction and engagement. 8

32. PCMH is a care delivery transformation focused on providing high-quality, safe, continuous, coordinated, comprehensive care, through a partnership between patients and their personal health care team 9

33. Highmark is committed to partnering with practice partners to achieve Patient Centered Medical Home

34. transformation Mutual Goals and Aligned Incentives 10

35. At full scale (2015-2016), the PCMH Model is anticipated to reduce medical spend of attributed Highmark members by 9.1% 11

36. Patient Centered Medical Home is the foundational building block to redesign the healthcare system. The goal of the PCMH is to effectively manage medical costs, while improving care quality and activating patients in their healthcare

37. Lessons Learned Transforming Care Delivery is difficult and complex Must address fragmentation and preventable waste Must align incentives for all stakeholders: Patients, Employers, Providers, Payers Must leverage data and information – Meaningful Use of technology (eMR, eRX, HIE, and Payer support) Must leverage transparency and communication among all stakeholders The Cultural Change for ALL Stakeholders to Transform Care Delivery – Requires “ALL IN” Team Based Partnerships Providers – Motivated and willing to redesign care delivery and coordinate care Patients/Healthcare Consumers – Actively engage in their care, healthy outcomes, informed care decision making : “Value Based Decision Making” Employers – Employee education, engagement and incentives Health Plans-Payers – Information/transparency, Provider partnerships and support- active collaboration to support accountable care transformation, payment reform- Value Based Payment Models and Member Benefit Designs

38. PCMH:A Physicians Perspective Sarah Chouinard, M.D. Medical Director Community Care of WV

39. “Even small healthcare institutions are complex, barely manageable places. . . Large healthcare institutions may be the most complex organizations in human history.” Peter Drucker Post-Capitalist Society. New York, Harper and Row, 1993